Wednesday , November 22 2017
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Diabetes Disaster Averted #37: Error Caught Just in Time

Recently, I had a type 2 patient using insulin to control their diabetes in the hospital overnight for minor surgery. One of the in-hospital interns reviewed their current medications and…

entered data into the system to continue with their ongoing medications including a rapid acting insulin prior to meals. The intern wrote the prescription for 3 U’s of insulin 10 minutes prior to meals.

The nurse read the prescription as 30, taking the U to mean zero (30 instead of 3U). I happened to walk into the patient’s room to check up on them and reviewed the chart as the nurse was filling the syringe with insulin. I noticed that she pulled back the plunger to load the 50 unit syringe 2/3’s of the way out. So I just questioned her as to the number of units she was going to inject and she said 30 units, which I immediately corrected to 3 units.

Lesson Learned:

There is a reason that the number one drug for errors is insulin. There are just too many possibilities for errors when insulin is involved. This is just one of them. So the lesson learned in this case is never use the abbreviated symbol of “U” or “IU” for units. You should always spell out the word “UNITS”!

Dr. Richard Harris, MD

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Diabetes in Control is partnered with the Institute for Safe Medication Practices (ISMP) to help ensure errors and near-miss events get reported and shared with millions of health care practitioners. The ISMP is a Patient Safety Organization obligated by law to maintain the anonymity of anyone involved, as well as omitting or changing contextual details for that purpose. Help save lives and protect patients and colleagues by confidentially reporting errors to the ISMP.

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